Healthcare Provider Details

I. General information

NPI: 1902684293
Provider Name (Legal Business Name): FAMILY WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 DAVID DR STE 103
MORGAN CITY LA
70380-1369
US

IV. Provider business mailing address

1234 DAVID DR STE 103
MORGAN CITY LA
70380-1369
US

V. Phone/Fax

Practice location:
  • Phone: 985-221-4436
  • Fax: 985-221-4567
Mailing address:
  • Phone: 985-221-4436
  • Fax: 985-221-4567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE MARIE PERRY
Title or Position: OWNER
Credential: NP
Phone: 985-714-9087